Arthritis Flashcards
What do you need to ask about in HPC?
Age and sex Joints - large / small / spine / sacral Long / gradual or sudden /acute Is pain better or worse on movement? Is stiffness worse in morning / after rest? Swelling?
What PMH/FH Qs are relevant to arthritis?
Arthritis
AID - hypothyroidism or T1DM
Inflam conditions - psoriasis, iritis, IBD
What SH Qs do you need to ask for arthritis?
Occupation - effect of symptoms on job
Smoking
What do you look for O/E of joints?
INSPECTION = Which joints? Swelling / rash / nail changes
PALPATION = temperature, tenderness, swelling - bony/soft?
MOVEMENT = range of movement, pain/crepitus on movement
Contrast active vs passive
Which type of movement mainly tests bones and not tendons?
Passive
List types of arthritis
Osteoarthritis
Rheumatoid
Crystal
Spondyloarthritis
What % of adults have osteoarthritis?
10%
Which joints do osteoarthritis affect?
Base & ends of thumbs, DIPJ, PIPJ
Hips, knees
List 3 components of osteoarthritis
Cartilage degradation
New bone formation - osteophytes
Inflammation - synovitis / effusion
What is PC of osteoarthritis?
Gradual
Pain on weight bearing joints
Stiffness for 30 mins
Swelling
List classic deformities of osteoarthritis
Heberdens nodes = DIPJ
Bouchards nodes = PIPJ
Squaring of thumb base
Varus at knee - medial cartilage wearing away
List XR changes of osteoarthritis
Loss of joint space
Subchondral sclerosis (thickening)
Cysts
Osteophytes
What is Mx of osteoarthritis ?
No disease modifying drugs
Education & physio
Pain relief
Pathophysiology of gout?
XS uric acid deposition
Where does uric acid come from?
Purine metabolism
Describe the uric acid crystals
Needle shaped negatively birefringent crystals
PC of gout
1st MTP in toe
Short, acute, VERY painful and stiff and swollen
+/- tophi
Ix for gout?
BLOODS: urate, CRP, ESR
XR of area
What will XR of gout show?
Early = nothing Late = rat bite erosions at side of bone
Mx of gout?
NSAIDs or colchicine (acute)
dietary advice +/- allopurinol (long term)
What enzyme metabolises purine?
Xanthine oxidase
What should be avoided in low purine diet?
BEER
Fish eg anchovies, mackerels
Game
Spinach, cauliflower, lentils, asparagus
What is a contraindication to allopurinol?
Azathioprine
What is pseudo gout?
Calcium pyrophosphate deposition
Shape of pseudo gout crystals?
positively birefringent rhomboids
To whom & where does pseudo gout occur?
Knees and wrists
Older females
What is the hallmark of RA?
Synovial inflammation
List polymorphisms that can lead to RA
HLA class 2 eg DR4 and DR1
What AB is present in RA?
Anti CCP
Is rheumatoid factor IgG or IgM?
IgM
PC of RA?
Polyarticular small joint stiffness Morning and post-rest stiffness Joint swelling FH of RA or AID Smoking is a risk factor
Who does RA affect?
40-50y/o females
Which joint is involved in RA?
MPJs
O/E RA?
Soft swelling
Painful on movement
Signs of uncontrolled RA?
Swan neck deformities Boutonnieres Z thumb Ulnar deviation at MCPs Wrist subluxation
Other signs outside of RA hands?
Atlanto-axial subluxation
Synovitis destroys transverse ligament
Systemic Sx of RA?
Episcleritis / scleritis / keratitis ILD Pericarditis / effusion Vasculitis Rheumatoid Nodules
XR features of RA?
Joint space narrowing
Periarticular osteopenia
Errosive damage
Joint deformities
If RA is suspected, how quickly do they get seen by rheumatology?
3 weeks
Ix of RA?
CRP/ESR
Anti CCP
RF
USS / MRI / XR baseline
What does RA predispose to?
Osteoporosis
Mx of RA?
Analgesia
PRN antiinflammatories
IM steroids
What are the disease modifying drugs for RA?
Methotrexate
TNF alpha blocker
Jakinibs
List 4 types of spondyloarthritides
Axial spondyloarthritis
Psoriasis arthritis
Reactive arthritis
Enteropathic arthritis
List common features of spondyloarthritides
HLA B27
Enthesitis
Arthritis
What is enthesitis?
Inflammation of where soft tissue insert into bone
What polymorphism is associated with spondyloarthritides ?
HLA B27
What is the hallmark of spondyloarthritides?
Enthesitis
List features of spondyloarthritides
Synovitis
Large joints
Some small joints
Dactylitis (swelling of whole digit)
What rash do you get on soles of feet in reactive arthritis?
Keratoderma blenorrahgia
Axial spondyloarthritides PC?
Male, <25
Inflammatory back pain insidious onset, pain at night, improves with exercise, worse with rest
Test for Axial spondyloarthritides?
Schober’s test lumbar forward flexion
Thoracic expansion
Imaging results for Axial spondyloarthritides?
Sacroilitis and shiny corner (enthesitis)
Posture of Axial spondyloarthritides?
Question mark posture
MRI findings of Axial spondyloarthritides?
Calcification of ligaments
Loss of joint space between vertebrae
Psoriatic features?
Scaly skin rash on flexures
Psoriasis on scalp
Nail changes- pitting and onycholisis
Reactive arthritis peripheral features?
Keratoderma blenorrhgagia (soles of feet and hands)
Conjunctivitis
Circinate balanitis
What organisms can trigger reactive ?
Chlamydia
Salmonella, shigella, yersinia, campylobacter
Who does enterohepatic arthritis affect?
IBD patients
Ix for Axial spondyloarthritides?
HLA B27
CRP/ESR
Imaging - MRI
USS for peripheral joint inflammation
Mx of Axial spondyloarthritides?
Analgesia NSAIDs Steroids Methotrexate TNF alpha blocker Jakinibs
Which drugs are disease modifying in Axial spondyloarthritides?
Methotrexate
TNF alpha blocker
Jackinibs